An alternative to open surgery: evaluating side effects

This study evaluated the sexual and anorectal (the final part of the large bowel) functions after rectal cancer removal and radiotherapy.

The rectum is the lowest part of the large intestine, located behind the urinary bladder and nearby the nerves and structures that control sexual function. Usually, patients who undergo open (abdominal) surgery and radiotherapy for rectal cancer develop complications such as sexual, urinary and anorectal (increased stool frequency and loss of bowel control) dysfunction. An alternative to open surgery is radiotherapy followed by local removal of the tumor during colonoscopy (examination of the inner part of the large bowel with a thin tube that has a camera attached to it). However, this intervention is limited to patients with small tumors and early stage cancer, due to an extremely high risk of recurrence (return of the cancer) in advanced tumors. Previous studies showed better anorectal and sexual outcomes after local cancer removal than after an abdominal surgery. However, it is unknown if the advantage remains if preoperative (before surgery) radiotherapy is added. 

This study included 44 patients with rectal cancer treated with local excision and preoperative radiation. All patients had tumors smaller than 3 cm. A control group consisting in 38 patients who had abdominal surgery (anterior rectal excision) without preoperative radiation was identified by computer search. The patients’ sexual and anorectal functions were assessed through a self-administered questionnaire.

Results showed that for both groups the most frequent anorectal dysfunctions were involuntary gas, involuntary stool loss, increased stool frequency and stool urgency. More than 50% of the patients in the local excision group reported involuntary gas or stool, numerous bowel movements and urgency and approximately 40% claimed that these dysfunctions worsened their quality of life. 11% to 21% of all patients reported these symptoms occurring often or very often. The evaluation showed that anorectal dysfunction was minor in 9% of the patients and major in 21% of the cases. The severity of each symptom was not different in both groups except for constipation, which was more frequent in patients treated with anterior excision only. Sexual functioning in men was significantly better in the local excision group compared with the control group, while in women there was no difference in sexual functioning between groups. 

In conclusion, the anorectal functions were worse than expected for patients treated with local excision and preoperative radiotherapy. The results suggest that radiation before surgery might diminish the advantage given by the local excision.

This study is limited by the small number of patients. Also, there was a lack of evaluation of the urinary function, which is a common problem after this type of surgery.

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